PERSONAL HEALTH; No Single Path for Cancer Care in Elderly

By JANE E. BRODY

Published: March 17, 2009

Elliot was 83 when a routine checkup that included a digital rectal exam suggested prostate cancer. A biopsy then revealed that he had an aggressive form of the disease. His doctor recommended treatment despite Elliot's age and several existing problems, including mild cases of high blood pressure, Type 2 diabetes, depression and angina, all of which were being treated with medication.

Elliot also has leg pain that limits his walking. But none of his health problems interferes with his weekly bridge game or nights out for the theater, concerts and dining. When cancer popped into the equation, Elliot, a man with a self-deprecating sense of humor always at the ready, said he was just not inclined to let it end his life.

So when the doctor suggested hormone and radiation therapy, five days a week for nine weeks, Elliot did not hesitate. Except for some radiation-induced fatigue that he noticed only after therapy was over, he sailed through the treatment. Three months after finishing his therapy, his P.S.A., a blood test for possible cancer, registered zero, suggesting that the malignancy was destroyed.

The outcome for Elliot is a direct assault on the oft-given advice that most cancers affecting people his age be left to take their course. The theory is that either the treatment will kill them or destroy their quality of life, or some other health problem will kill them before the cancer does.

But there is a great paucity of factual information to support either a wait-and-watch approach or an aggressive approach to treating cancer in the elderly.

Although about 60 percent of newly diagnosed cancers occur in people 65 and older, there is little research to help doctors and patients decide how, when and even whether to treat the many forms of cancer that afflict older people, especially those with other ailments that can complicate therapy.

Limited Research

For a variety of reasons, older cancer patients are rarely included in clinical trials that test new therapies, so relatively little is known about potential responses to treatment under various circumstances.

Research protocols commonly eliminate people with chronic health problems, in case the therapy makes those problems worse or the medications patients are taking interact poorly with the treatment being studied. Another deterrent is limited longevity in the elderly, making it difficult to determine the long-term effectiveness of a treatment.

Patients themselves can be a problem, if they fear ''being experimented upon,'' if they are not physically able to get to treatment facilities, or if the research protocols are too difficult for them to understand and follow.

Despite the limited research, one fact is clear: there is no ''one size fits all'' treatment for cancer in the elderly. Whether the patient is 60, 80 or 100, a host of factors -- medical, practical and emotional -- must be taken into account when devising a therapeutic plan. To the distress of some families, decisions are too often based more on a patient's chronological than physiological age.

''The doctor may be dealing with two 65-year-old patients with the same disease,'' Dr. Jerome W. Yates, national vice president for research at the American Cancer Society, said in an interview. ''Yet one is like a 55-year-old, healthy, strong and resilient, and the other is more like an 85-year-old, frail and chronically ill. Each should be treated differently.''

Treatment decisions should be influenced by patients' physical and mental health, of course, but also by their financial status, living situations, family support systems and ability to get to and from the treatment facility, Dr. Yates said.

Don't Forget the Patient

Still another consideration, Dr. Yates said, and not a small one, is what the patient wants. He described a former patient, a 78-year-old woman with diabetes who had lost a leg to osteogenic sarcoma. The cancer had spread to her lungs, and she faced possible treatment with chemotherapy that would cause nausea and hair loss and carried the risk of a fatal lung infection. Her four college-educated children agreed with the doctor's suggestion to skip chemotherapy and administer comfort care, since treating her cancer was likely to kill her.

''But she said she wanted to be treated -- she was adamant,'' recalled Dr. Yates, who will be leaving the cancer society for the National Institute on Aging. ''To my surprise, she had a dramatic response to the treatment. Her lung tumors all but disappeared, and she lived another two years.''

Barbara and Charles Given, family care cancer specialists at Michigan State University, told a national conference on cancer and aging in 2007 that older patients, ''when they are selected carefully, appear to tolerate and respond well to cancer treatments.''

They added that older patients who have had surgery for lung cancer or have been treated for cancers of the colon, rectum, breast or prostate, or non-Hodgkin's lymphoma, ''all have tolerated and shown positive responses to their treatments.'' And those with a life expectancy of more than five years have also benefited from additional therapies, like postoperative radiation or chemotherapy, they reported.

Still, out of fear that the side effects of cancer treatment will hasten an older patient's death or destroy the quality of the remaining years of life, doctors often undertreat the elderly, indirectly hastening their death with less-than-optimal therapy.

In other cases, elderly cancer patients are overtreated despite the likelihood of life-threatening complications, because doctors fear being accused of giving up or are pressured by family members to provide therapy that is medically inappropriate.

Full Disclosure

One of the greatest challenges clinicians face with elderly cancer patients is incomplete information about their health.

''There is often a lack of documentation about pre-existing problems,'' Dr. Yates said. ''A patient may suffer from chronic alcoholism or a psychiatric condition that would interfere with cancer treatment, yet such problems are often not disclosed. Or, if an older person has five or six medical conditions, it's not unusual for them to mention only the most prominent condition, the one that bothers them most at the moment.''

Patients should be prepared to give their full medical history, and caregivers and family members should help fill in the blanks if necessary. In addition, Dr. Yates suggested that treatment decisions for the elderly be family decisions, since older patients must often depend on their children to make therapy happen.

But he also warned that family members should not insist on aggressive treatment that the doctor considers futile. If the family has good reason to doubt the doctor's judgment, an independent second opinion should be sought, he said.

There are nonthreatening ways to expand the conversation about treatment options, Dr. Yates said, starting with a couple of perfectly reasonable questions for the doctor: ''Is this the best option? If this were your mother or father, what would be your recommendation?''